Pediatric Advance Life Support: Unstable Bradycardia

Primary Causes

·         Heart blocks (congenital heart disease)

·         Heart transplants (vagal denervation)

·         Cardiomyopathies

·         Myocarditis

·         Surgical injury to pacemaker or conduction system

Secondary Causes

·         Hypoxemia

·         Hypothermia

·         Hypothermia

·         Head injury

·         Acidosis

·         Toxins- Digoxin, Beta Blockers, Calcium channel blockers

·         May be induced by excessive vagal stimulation from suctioning or intubation

Management

·         Most clinically significant bradydysrhythmias are caused by hypoxemia

·         Treatment aimed at airway support, ventilation and oxygenation

·         CPR is indicated for heart rates less than 60 and accompanied by hypotension

Note:  Because unstable bradycardia usually arises secondary to a respiratory problem, the initial goal is to secure the airway and establish adequate oxygenation and ventilation. Initiate bag-mask ventilation with high-concentration oxygen, and then reassess the patient’s heart rate and perfusion. If bradycardia and poor perfusion persist, provide chest compressions until the heart rate exceeds 60 beats per minute. If necessary, perform endotracheal intubation

Primary Survey

·         Airway:  Support airway

·         Breathing:  give 02, assist with bag mouth ventilation, attach pulse oximeter

·         Circulation:  Monitor BP, attach defibrillator/monitor, Establish IV/IO access, 12 lead EKG, labs

Note: Initiate bag-mask ventilation with high-concentration oxygen, then reassess the patient’s heart rate and perfusion. If bradycardia and poor perfusion persist, provide chest compressions until the heart rate exceeds 60 beats per minute.

Assess for cardiopulmonary compromise

·         Hypotension

·         Respiratory compromise

·         Shock with hypotension

·         Altered mental status

·         Sudden collapse

·         Cold, clammy skin

·         Delayed capillary refill

·         Absent or weak pulses

Note:  A child with unstable bradycardia usually demonstrates ineffective respiration marked by slow, irregular breathing and poor perfusion. Evaluate the patient for signs of compromised cardiac output, including reduced responsiveness, weak central pulses, weak or absent peripheral pulses, hypotension, delayed capillary refill, and cool extremities. A focused history and physical examination may identify potential causes, such as respiratory problems, fever or significant fluid loss.